Policies and Forms

Claims

BCBS Claim Form

Use this form to request reimbursement when you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan.

Claim Form Online Submission (International Claims Excluded)

To submit a claim online (medical or dental), login to MyBlue and complete the information on the screens that follow. International claims are excluded (see international claims section for reimbursement instructions).

BCBS International Claim Form

Use this form to request reimbursement for covered out-of-pocket expenses that you incurred outside of the United States while actively covered under the Student Health Insurance Plan. Students should use this form for medical claims.

BCBS Weight Loss Reimbursement Form

Use this form for reimbursement for qualifying weight loss programs.

To submit a claim online (medical or dental), login to MyBlue and complete the information on the screens that follow. International claims are excluded (see international claims section for reimbursement instructions).

Childbirth Classes

Use this form for reimbursement for qualifying childbirth classes.

To submit a claim online (medical or dental), login to MyBlue and complete the information on the screens that follow. International claims are excluded (see international claims section for reimbursement instructions).

CVS Caremark Prescription Drug Claim Form

Use this form if you need to file for reimbursement for expenses you paid out of pocket on prescriptions. You will not be reimbursed for applicable co-payments/coinsurance. 

Travel Benefit Reimbursement Form

Under the medical benefits travel rider, Blue Cross Blue Shield of Massachusetts will reimburse members for certain expenses related to travel to obtain covered services other than routine or preventative care when access to those services is not available within 100 miles of the member’s home and the member must travel to obtain the services.

BCBS Dental Blue Claim Form

Use this form to request reimbursement for covered out-of-pocket expenses (excluding required deductible/coinsurance) that you may have incurred while actively covered under the Dental Blue Plan.

Enrollment Forms

Dental

Open enrollment ends September 30. Students enrolling in an individual plan must use the student insurance portal. Students enrolling with their dependents should use the dental application available on our website’s dental section.

Leave of Absence

Students taking a leave of absence can purchase a 6-month extension of the coverage they had prior to taking their leave. View the leave of absence page for the full policy and application.

Post-Doc Affiliate Enrollment

Post-doctoral affiliates (also known as post-doctoral fellows) are eligible to enroll as long as they have a current appointment, were recently awarded a Ph.D. or equivalent doctorate in an appropriate field, and are not eligible for employer-sponsored health insurance.

Student Dependents

Dependent enrollment must be completed online only. Visit the student dependent enrollment page for the full policy and application.

Policies

HUSHP Dependent Medical Cancellation Policy & Application

A student may request a cancellation of the Harvard University Student Health Program for their dependent(s) through Member Services. This request will cancel both parts of the insurance, the Student Health Fee and the Student Health Insurance Plan; the option to cancel only one part of the program is not available. The date we receive the cancellation form will determine cancellation options.

  • You may request a cancellation of the Harvard University Student Health Program for your dependent(s) through Member Services.
  • This request will cancel both parts of the insurance, the Student Health Fee and the Student Health Insurance Plan.
  • You cannot cancel only one part of the program.
  • The date we receive the cancellation form will determine cancellation options. View cancellation policy and application.

Affiliate Health Insurance Cancellation Policy

A previously enrolled affiliate may request a cancellation of the Harvard University Student Health Program for themselves or their dependent(s) through Member Services; limitations and deadlines apply. 

  • This request will cancel both parts of the insurance, the Student Health Fee and the Student Health Insurance Plan. 
  • The option to cancel only one part of the program is not available. 
  • The date we receive your cancellation form will determine your cancellation options.

Active Duty Military Attestation

Active military duty personnel may be eligible to waive the Student Health Fee. Complete the attestation form and return it to Member Services.

Leave of Absence/Withdrawal

Students may apply for six months of additional coverage due to Leave of Absence or Withdrawal from the University.

Waiver Rescind

This policy details how a student can re-enroll in HUSHP if they waived and lost their waived health insurance plan or are trying to re-enroll before the waiver deadline. 

November Degree

This policy outlines what happens to a student’s coverage when they are a November degree candidate.

Medicare Certification

This form is for members to declare their eligibility for Medicare.

Dental Blue Cancellation Policy

Students may elect to cancel the option Dental Blue Plan if they meet the criteria.

Dental Blue Change in Plan Type

Students may elect to change the Dental Blue Plan in which they enrolled if they meet the criteria.

Qualifying Life Events

Students and their eligible dependents may opt into the medical and/or dental plan outside of the open enrollment periods if they have experienced a recent qualifying life event.

Pending Enrollment Waiver Policy and Application

This policy is for students who plan on waiving, but their insurance coverage will not become effective until sometime between August 1 and October 1 (fall term) or February 1 and March 1 (spring term).

Cost Estimates

Members can request a cost estimate if they meet eligibility guidelines and are currently enrolled in the health plan. An estimate does not guarantee coverage, and each admission, procedure, or service must be a medically necessary covered benefit and meet medical guidelines. All prior authorization and referrals must be obtained if required.

There are two options for receiving an estimate of your financial responsibility for an upcoming service or procedure.

Estimates from Your Insurance Plan

Estimates from Your Provider

  • Contact your provider’s office directly and ask for an estimate of your out-of-pocket costs for the services you are expecting to have.
    • All providers are now required to provide cost estimates for their services.
Tax Information

Tax Forms

The Affordable Care Act requires the Harvard University Student Health Program (HUSHP) to provide membership information for the calendar year to the Internal Revenue Service.

Members enrolled in the Student Health Insurance Plan (Blue Cross Blue Shield of Massachusetts) should expect a 1099-HC form and, depending on where your address was recorded, a 1095-B form.

1099-HC

​​The 1099-HC form is applicable only when filing taxes in Massachusetts. Blue Cross Blue Shield of Massachusetts mails the 1099-HC form to all subscribers by January 31 of the following year. If you did not receive a 1099-HC form and would like to request a copy, please call Blue Cross Blue Shield of Massachusetts at 800-257-8141 or request a form online through MyBlue.

You can download a copy online by following these instructions:

  • Log in to MyBlue
  • Click on “My Inbox” at the top of the page
  • From there, click on “Documents” and then “Tax Forms”

1095-B

Students whose address was recorded as being in RI, NJ, DC, or CA for 2021 will receive a printed form from our vendor, Thomson Reuters. This form is for your tax records and confirms that you were enrolled in a plan that met minimum essential coverage requirements. 

You do not need this form to file your federal taxes.

If your address was recorded as being in RI, NJ, DC, or CA and you did not receive a 1095-B form, contact HUSHP Member Services. Learn more about the Internal Revenue Service requirements or view a sample 1095-B Form.

What information do I need to file my taxes?

  • Your Blue Cross Blue Shield policy ID number
  • The Federal ID (FID): 04-1045815
  • The months in which you were insured

International Students

This form may not apply to all students, particularly those who do not file taxes in the United States with the Internal Revenue Service. Additionally, please be aware that if your 1095-B includes an SSN and you do not have a federally issued SSN, this is because Blue Cross Blue Shield of Massachusetts had to create a pseudo (fake) SSN for you to be enrolled in their system. This does not mean that the government has issued you an SSN. Please consult a tax advisor if you have questions.

Students without a Social Security Number (SSN)

Please be aware that Blue Cross Blue Shield of Massachusetts created a numeric code to enroll you in health insurance. That numeric code is displayed on your 1095-B form and IS NOT an SSN issued by the United States government. Please consult a tax adviser if you have questions.